Motor Vehicle Request Form

Purpose - This form initiates the use of a State owned vehicles from the College motor pool, if available. Motor Vehicle Requests are to be based on an approved Travel Authorization

Instructions -Fill out this form, print out, sign (in ink), and submit to approving authorities. Motor Vehicle Requests are to be submitted at least
2 weeks before vehicle is required to the Physical Plant Services.
Origination Date: Requestor:
Vehicle Requested: Campus Phone  #:
# of Passengers:    Responsible Dept:
Driver Needed:

Yes

No Budget Code:
Destination: Pickup Date/Time:
Return Date/Time:
Purpose:

Risk Management Vehicle Use allow the following guidelines for drivers of State Vehicles; CRS 24-10-106 (a) public employees while in the course of employment, CRS 24-10-103 (1) (4) (a) a public employee is defined as public entity employee or AUTHORIZED VOLUNTEER.  An authorized volunteer is defined as - a person who performs an act for the BENEFIT at the REQUEST and subject to the CONTROL of the public entity.  Whether a club or student government driver is an AUTHORIZED VOLUNTEER may turn on management decision regarding vehicle use.  There are no statutory citations on this subject.

Driver 1: Driver 2: Driver 3:
DL/ CDL #:  DL/ CDL #:  DL/CDL #:
Phone Ext: Phone Ext: Phone Ext:
State Employee State Employee State Employee
Authorized Volunteer* Authorized Volunteer* Authorized Volunteer*

*Documentation must be supplied.

Driver acknowledges use of this vehicle will be in accordance of all Colorado State Laws.  Colorado Risk Management will not become involved in coverages unless the vehicle is operated by a State employee (or ‘authorized volunteer’ as defined at CRS 24-10-103) while in the course of employment.

The additional Driver(s) listed above are Colorado State Employees (or 'authorized volunteers') and will be under my control and direction to drive the rented vehicle for me and in my behalf.  I am responsible for their acts while they're driving, and for fulfilling terms and conditions of this agreement.

The use of this vehicle shall not be used for any purposes, which do not comply with State of Colorado laws and FLC Policies.  By signing below, I understand and will follow the laws and policies set forth.  Furthermore, I have a clean driving record and carry personal vehicle insurance that will cover damages and liabilities that occur while negligent outside of the course of Colorado State business designated above.

Driver/Authorized Volunteer:

____________________________

_____________

     
Signature (Ink) Date

Approvals
_________________________     ____________     ______________________     ___________

Department

Date

Cost Center Director

Date

Motor Pool Only
(On File)
  

Driver 1

     Driver 2     Driver 3    
    Authorization: ___Yes ___No  Authorization: ___Yes ___No    Authorization: ___Yes ___No
Driver's License: ___Yes ___No Driver's License: ___Yes ___No Driver's License: ___Yes ___No
CDL License: ___Yes ___No CDL License: ___Yes ___No CDL License: ___Yes ___No

Designed by PIH 8/02
Received By: _______________________________ Date:

______________________